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F0773
D

Delay in Obtaining Lab Results and Initiating UTI Treatment

Goshen, Indiana Survey Completed on 06-02-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to obtain laboratory results and initiate antibiotic treatment for a urinary tract infection (UTI) in a timely manner for a resident with a history of UTIs, dementia, and type 2 diabetes. The resident, who was severely cognitively impaired and required assistance with toileting and bathing, had been seen by a gynecologist and had a vaginal swab and urine test completed to check for infection. Facility documentation indicated that staff were instructed to call back for test results, but after an initial unsuccessful attempt to contact the OB/GYN office, there was no documentation of further attempts between 5/16/2025 and 5/23/2025 to obtain the results. The urinalysis results, when finally obtained, showed a positive result for E. coli, and an antibiotic was ordered and delivered several days later. The first dose of the antibiotic was not administered until after the medication was received, resulting in a delay in treatment. The Director of Nursing acknowledged the lack of timely documentation and follow-up to obtain the test results, as well as the delay in medication delivery. The facility's policy required that completed culture reports be reviewed and orders obtained as soon as possible, which was not followed in this instance.

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